Surgery for Ascending Aortic Aneurysm and Aortic Valve Insufficiency in Conditions of Active Proceeding Syphilitic Aortitis and Valvulitis

A syphilitic aortitis is a late cardiovascular lesion of tertiary syphilis that has become exceptionally rare in the antibiotic era but not eradicated completely. Syphilitic aortitis of ascending aorta complicates in ascending aortic aneurysm formation and aortic valve regurgitation, both requiring surgical treatment. After surgery, lifelong surveillance of the remainder of the aorta is recommended because of a priori supposed high incidence of delayed involvement of noninvolved aortic segments. A 3-year follow-up result of surgery of syphilitic ascending aortic aneurysm with aortic valve regurgitation in condition of active ongoing syphilitic aortitis and valvulitis is described with addressing the dimensions of remaining aortic segments. This case demonstrates that the dilatation of the remainder of the aorta does not occur during 3 years, at least when anti-syphilitic course of antibiotic is used just after operation without additional treatment during the follow-up period. A few reports on surgical treatment of syphilitic aneurysms of the ascending aorta are discussed.

[Hybrid Two-stage Repair of Syphilitic Aortic Aneurysm, Total Arch Replacement and Thoracic Endovascular Aortic Repair;Report of a Case]

Syphilitic aortic aneurysm is seldom seen in the antibiotic era. Statistically the number of patients is increasing today and 10% of them seem to develop syphilitic aortitis. A 59-year-old male visited the emergency room due to chest discomfort and general fatigue. Treponema pallidum latex agglutination (TPLA) and rapid plasma reagin (RPR) were both strongly positive on blood tests. White blood cell counts and C-reactive protein elevation were also found. He couldn't figure out how or when he was suffering from syphilis. He needed to undergo a hybrid 2-stage surgery urgently, Total arch replacement and thoracic endovascular aortic repair (TEVAR), because his thoracic aortic aneurysm was growing more rapidly. No complication has occurred during or after surgery. Computed tomography after surgery showed successful exclusion of the thoracic aneurysm. It is important not to forget that syphilis is one of the causes of aortic aneurysm.

A case report of CT-diagnosed renal infarct secondary to syphilitic aortitis

BACKGROUND

Even though reported cases of syphilis have been increasing, cases of tertiary syphilis remain extremely rare. The majority of our knowledge with regard to complications of syphilis such as aortitis was acquired before the advent of relatively modern technologies such as CT, MRI and PET. This case report presents a rare case of syphilitic aortitis associated with a renal infarct caused by a peripheral arterial embolism diagnosed by CT.

CASE PRESENTATION

We present a young man with sudden abdominal pain and flank tenderness without fever. Blood tests showed acute kidney failure. Computed tomography showed a right renal infarct and a non-circular thickening of the descending thoracic aortic wall with intra-luminal thrombus. Serology confirmed the diagnosis of syphilis. Treatment with anticoagulant and penicillin resulted in a good outcome. Follow-up PET-MRI showed resolution of the thrombus with a metabolically inactive atheromatous plaque.

CONCLUSION

Technologies, such as CT, PET-CT and PET-MRI, that were not present during the pre-antibiotic era, can provide new insights into rare presentations of tertiary syphilis such as aortitis. These imaging modalities show promise for early radiological diagnosis of aortitis in syphilis and may be useful for determining the response to treatment in specific cases.

Syphilitic Aortitis Presenting with Coronary Ostial Stenosis and Aortic Regurgitation

Bilateral coronary ostial stenosis without additional coronary artery involvement is a rare presentation of syphilitic aortitis, with most cases being identified post-mortem. Herein is presented a case of bilateral coronary ostial stenosis and aortic valve insufficiency caused by syphilitic aortitis without aneurysmal dilatation of the aorta. The patient underwent aortic root replacement and coronary artery bypass grafting. The intraoperative macroscopic findings raised the suspicion of an aortitis that was later confirmed to syphilitic aortitis on histological examination. It is of note that syphilis can be a cause of bilateral ostial stenosis in young adults with no predisposition to atherosclerosis, especially if combined with aortic insufficiency resulting from an isolated leaflet dysfunction.

Computed Tomographic and Morphologic Features of Syphilis of the Aorta

This report describes certain computed tomographic and morphologic features of syphilitic aortitis in 2 patients in whom the process involved the entire thoracic aorta.

Syphilitic arteritis involving the origin of the cervical internal carotid artery

We report a case of meningovascular syphilis in a young adult woman presenting with left hemiparesis due to near occlusion of proximal cervical internal carotid with subacute middle cerebral artery territory infarction. Diagnosis was made on the basis of positive serum, and spinal fluid serology for syphilis, carotid Doppler, and magnetic resonance angiography, as well as improvement after intravenous penicillin therapy. In this case report, the imaging findings were described and related literature was reviewed.

Austin Flint murmur re-visited

Austin Flint murmur is a mid-diastolic rumbling audible in subjects with severe aortic regurgitation. Several theories have been raised to explain mechanistically the nature of this particular phenomenon. We briefly review severe aortic regurgitation under the light of contemporary echocardiography in an illustrative case.

[Cardiovascular syphilis: diagnosis, treatment]

Cardiovascular tertiary syphilis may lead to aortitis, aortic aneurism, coronary stenosis, aortic insufficiency and, rarely, to myocarditis. The physician must be familiar with the clinical presentations of this process, including the asymptomatic variety and must be able to have an organized plan for the diagnosis and evaluation to establish or exclude the presence of cardiovascular pathology and the differential diagnosis with other entities. Once the etiologic and topographic diagnosis is established, the patient should be treated with penicillin, doxicycline and other antibiotics, and the consequences of the disorder, both actual and potential, should be considered before deciding weather to recommend surgical intervention. Although late syphilis can be prevented by appropriate therapy of early syphilis, this is a cardiovascular disease that most likely will continue to be diagnosed lately. Understanding of the pathology and pathophysiology of the disease, is most important for its prompt recognition and subsequent management. This paper reviews the natural history, diagnosis and therapy of cardiovascular syphilis.

Early sternal erosion and luetic aneurysms of thoracic aorta: report of 6 cases and analysis of cause-effect relationship

Six patients with luetic aneurysm of the ascending aorta eroding the sternum are presented. The erosion was an early and principal presentation and the site of erosion and location and morphology of aneurysm were identical in all six patients. The erosion mainly affected the right half of the manubrium and medial end of right clavicle. The aneurysms arose from the junction of the ascending and transverse arches of the thoracic aorta and had narrow opening close to the origin of the innominate artery. The identical presentation, aetiology, angiographic location and morphology, corroborated further at surgery, suggests that syphilitic aneurysms in this location have a strong tendency to cause early sternal erosion.

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis

A 49-year-old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.

Penetrating ulcer of ascending thoracic aorta in syphilis

Penetrating aortic ulcers (PAUs) are rare exotic pathological entities, classically located in the descending thoracic aorta. Their association with syphilis has never been reported. We describe a first case of a patient with cardiovascular syphilis presenting as PAU in the ascending aorta.

[Cardiovascular syphilis: a case report]

Nowdays, cardiovascular manifestations of syphilis are uncommon. We report the case of a 69-year-old man who underwent surgery for saccular aneurysm of the ascending aorta associated with aortic regurgitation of this etiology, due to sexual transmission of the disease 25 years previously. The patient was born in Morocco and 2 years after surgery he remains asymptomatic.

A ruptured syphilitic descending thoracic aortic aneurysm. The characteristic findings on computed tomography for the etiological diagnosis of aneurysm

We report the case of a 72-year-old man with a ruptured syphilitic descending thoracic aneurysm who underwent an emergency operation and successful graft replacement. Preoperative physical examination showed a pulsative mass on the left back. Preoperative computed tomography showed bone destruction in the TH6 to TH10 thoracic vertebrae and ribs and penetration (or rupture) of the aneurysm into the subcutaneous tissue. During the period of preoperative evaluations, free wall rupture of the aneurysm occurred and emergency operation for graft replacement was performed. The microscopical examination of the aneurysmal wall revealed the syphilitic changes. In literature, the vertebral destruction by atherosclerotic aneurysm is usually located at the TH12 to L3 of vertebral bodies. From the findings of this patient and a study of existing literature, we concluded that the finding of vertebral bone beyond TH12 to L3 region on CT examination of the aneurysm could be a etiological characteristic finding for syphilitic aortic aneurysm.

[Thoracic imaging in the elderly]

In our hospital, 30% of plain chest radiographs are performed in patients over 70. Somewhat surprisingly, few papers specifically dealing with the aging lung are available in the radiological literature. It is obvious however that the differential diagnosis of a chest lesion is not the same if the patient is 40 or 70. A false positive diagnosis is a frequent potential mistake in aging subjects, for example: chondral calcification versus pulmonary nodule, hyperinflation versus emphysema, "normal aging" bronchial and tracheal calcification versus hypercalcemia, diaphragmatic defect versus tumor, diaphragmatic pseudotumor versus lymph node, false diagnosis of aortic knob dissection, false diagnosis of syphilitic aortitis, inaccurate CT-detection of valvular and coronary calcifications, confusion between valvular and annular mitral calcification. Much work is still needed to exploit CT in its clinical applications for the aging lung.

Aortic dissection and cardiovascular syphilis: report of an observation with transesophageal echocardiography and anatomopathologic findings

We report the case of a man who had thoracic pain and stroke. Transesophageal echocardiography enabled us to diagnose an intramural hematoma and a saccular aneurysm of the thoracic aorta before he died. Autopsy showed lesions compatible with syphilitic aortitis in the aortic wall. Transesophageal echocardiography and anatomopathologic findings are correlated, and the role of syphilis as a causal factor is discussed.

Clinically isolated left coronary ostial stenosis: a manifestation of cardiovascular syphilis--case history

The authors report a case of clinically isolated left coronary ostial stenosis in a thirty-seven-year-old man as a manifestation of cardiovascular syphilis. Notably he was free of the usual risk factors for coronary artery disease, and the rest of the coronary tree was angiographically normal.

[Multiple cerebrovascular lesions as fatal late sequelae of syphilis]

A previously healthy man, aged 33 years, suddenly developed a hemiparesis and right facial paresis, as well as anisocoria and motor aphasia, preceded by recurrent attacks of dizziness. On admission he was somnolent. A flow murmur was heard over both carotid arteries; the blood pressure was 160/80 mm Hg. Cerebral computed tomography demonstrated multiple hypodense areas in the area supplied by several cerebral arteries, and marked cerebral oedema. Angiography of the aortic arch and the supra-aortic branches showed an occlusion of the left common carotid artery and a stenosis of the brachiocephalic trunk. The cerebral oedema, caused by ischaemia, did not respond to treatment. The patient died on the fourth hospital day from brainstem "strangulation". At autopsy syphilitic mesaortitis with characteristic lymphoplasmacellular endangiitis of the vasa vasorum of the aortic arch was demonstrated as the cause of the "aortic arch syndrome". Serology confirmed the diagnosis of an untreated tertiary syphilis. (VDRL titre 1:256; TPHA reactive; IgM-SPHA titre 1:64). Although a very rare cause, a late stage of syphilis should be considered in the differential diagnosis of cerebrovascular lesions in youngish patients.

[Surgical treatment of syphilitic ascending aortic aneurysm: a case report]

A 67-year-old man with positive serum reaction for syphilis had been followed by cardiologist for his moderate-sized saccular ascending aortic aneurysm and small-sized abdominal aortic aneurysm. Because of his transient ischemic attack probably secondary to the thrombo-embolism of the aneurysm and rapid growing of its size, surgical treatment was recommended. Resection of the saccular aneurysm with patch plasty of the ascending aorta was performed under the cardiopulmonary bypass associated with right side cerebral perfusion. At the time of operation, the mildly dilated ascending aorta and arch with multiple intimal ulceration were noted. Although his postoperative hemodynamic condition was stable, he suffered from multiple cerebral infarction, probably due to embolism migrated from the fragile aortic intima. His neurological condition was improved promptly, trivial hemi-paralysis was remained. The specimen of resected aneurysmal wall revealed syphilitic changes microscopically. We concluded that the extent of the aortic replacement with prosthetic graft should be deceived not only with its external appearance, but also with the changes of its inside.

Compression of pulmonary artery by syphilitic thoracic aortic aneurysm: imaging

A case of syphilitic aortitis with multiple thoracic aneurysms, one of which caused compression of the left pulmonary artery with hypoperfusion of the left lung as seen with perfusion scintigraphy, blood pool studies, CT, and magnetic resonance imaging is presented.

Progressive thoracic aortic dilatation after aortic valve replacement

Aneurysms of the ascending aorta developed after aortic valve replacement for chronic aortic insufficiency in four cases. Two of the aneurysms were complicated by dissection; one patient died. Rheumatic disease has become a less common cause of pure aortic regurgitation, and a number of etiologies primarily involving the wall of the aorta are now recognized. Although appropriately timed aortic valve replacement can prevent the irreversible left ventricular depression associated with chronic aortic insufficiency, careful evaluation of the thoracic aorta on serial postoperative chest radiographs is warranted, because the underlying pathologic process may proceed in the aortic wall with eventual aneurysm formation.

Surgical treatment of syphilitic coronary ostial stenosis with aortic regurgitation

Syphilitic aortitis leads to involvement of the coronary ostia, aortic annulus and valve leaflets. Aortic valve replacement (AVR) with restoration of coronary blood flow is an essential therapeutic objective. Three different approaches were used for the treatment of syphilitic aortic regurgitation with coronary ostial stenosis; Case 1. AVR and endarterectomy, Case 2. AVR and aorto-coronary saphenous vein bypass graft and Case 3. AVR and endarterectomy using Fogarty catheter and Scanlan Aorta Punch. Special emphasis was given to the technique used in Case 3 as a therapeutic adjunct in the treatment of syphilitic coronary ostial stenosis.

[Spontaneous perforation of a syphilitic aneurysm of the aortic arch into the pulmonary artery]

An aortopulmonary fistula in case of a bag-shaped aneurysm of the aortic arch is demonstrated via angiography. A diagnosis to the effect that the existence of this phenomenon is suspected, can already be arrived at when examining the plain radiography of the thorax. We can say that a sign of an aortopulmonary fistula is represented, in case of an aneurysm of the aorta ascendens and of the arcus aortae, by the existence of a left-right shunt with hypercirculation in the pulmonary circulation, in most cases also signs of right ventricular insufficiency. This is often combined with a typical previous history of sudden dyspnea and thoracic pain. The article points out the theoretical possibility of balloon catheter occlusion of the fistula to relieve the acute right ventricular load.

[Roentgen signs of rare mediastinal masses (author's transl)]

Mediastinal masses are commonly classified into lesions of the anterior, middle, and posterior compartment as a first step in differential diagnosis. Teratoma, neurogenic tumors, goiters, and thymoma with their characteristic localization constitute together already two thirds of all mediastinal neoplasms. However, the differential diagnosis of mediastinal masses should include also rare diseases: lymphangio-hemangioma, aneurysm of the pulmonal artery, intrathoracic meningocele, esophageal cyst, and pleurobronchial cyst are demonstrated. It is emphasized, that differential diagnosis has to consider history and physical data of the patient as well.

Angiographic differentiation of thoracic aneurysms and neoplasms

The distinction between nondissecting aneuryms of the thoracic aorta and thoracic neoplasms may be difficult. The aortographic findings associated with aneurysms may be subtle. However, when the aortogram is properly performed and interpreted and the findings correlated with the plain chest roentgenograms the distinction between aneurysms and neoplasms may be made consistently. The thoracic aortogram should be filmed in at least 2 projections and abdominal aortography and ultrasonography should be performed. With aneurysms the aortographic signs include widening (often slight) of the aortic lumen, thickening of the aortic wall, small ulcer-like collections of contrast and non-filling of regional intercostal arteries. With neoplasms none of these radiological features is to be anticipated, while the aorta will be normal, displaced or narrowed.

Observations on the natural history of atherogenesis

Longstanding scoliosis of the lumbar spine with convexity to the left leads to severe atherosclerosis in the adjacent segment of the abdominal aorta. By contrast, the lateral wall of the ascending aorta, which is free to pulsate, usually is not affected even in very old persons. This relative immunity, however, is not maintained in cases of syphilitic mesaortitis; damage to the elastic tissues of the media leads to atherosclerosis. Man is the only mammal known to be highly susceptible to severe atherosclerosis. The concept is advanced that the erect posture of man, which leads to the physiologic anterior curvature of the lumbar spine, predisposes to atheroma formation in the abdominal aorta, particularly in women. Evidence for the osteoporosis-atherosclerosis concept is presented. Sustained muscular activity starting early in life can delay osteoporosis and atherosclerosis. A possible mechanism for the onset and gradual progression of physiologic osteoporosis is suggested. The concept of atherogenesis advanced here is based on observations which suggest a correlation of aging processes in the mesenchymal tissues. These aging processes, in conjunction with mechanical factors partly caused by the erect posture, may account for the unique susceptibility of man to severe atherosclerosis.

[Inflammatory cerebro-vascular disease: angiographic findings and distribution patterns (author's transl)]

Although cerebral angiography should be approached with caution in the diagnosis of inflammatory cerebro-vascular disease there are some characteristic angiographic findings which may be helpful for classification and differential diagnosis. The proximal cerebral arteries are favourably affected by basal meningitis and thrombangiitis obliterans with resulting stenoses and occlusions. Whereas those inflammations originating from neighbouring skull structures mostly involve the intracavernous parts of the carotid artery, the tuberculous and mycotic arteritis prefer the supraclinoid carotid siphon. Peripheral vascular changes are found in luetic endangiitis, necrotizing and toxic angiitis and in collagenoses. Simultaneous involvement of the temporal arteries is of great diagnostic importance demonstrating the systemic character of the inflammatory process; in Horton's arteritis it can be a pathognomonic finding. Infectious endocarditis, some mycoses and malaria may lead to embolic occlusion of cerebral vessels. Mycotic aneurysms mostly have a broad base or a fusiform shape and do not prefer the localizations of congenital aneurysms. Angiographically, abscesses, tuberculomas and viral encephalitis may result in circumscribed hypervascularized areas. The characteristic angiographic findings are exemplified and discussed on the basis of 8 cases of inflammatory cerebro-vascular disease (tuberculosis, pneumococcal and unspecific bacterial meningitis, syphilis, mycosis, Takayasu-syndrome, panarteritis nodosa, temporal arteritis).

Roentgenology of sinus of Valsalva aneurysms

Aneurysms of the sinuses of Valsava are neither rare nor always fatal. They are of three types: congenital, acquired, and associated with cystic medial necrosis. Each can be recognized by its characteristic appearance on plain roentgenograms and arteriography. With surgical repair, the congenital type and that which is the result of cystic medial necrosis carry a good prognosis for the patient. With the acquired type, usually syphilitic, the prognosis with conservative management is good.